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SIGN stroke guideline addresses needs of patients with dysphagia

Dysphagia is a common complication of stroke, often with serious consequences, but early detection can help to reduce morbidity, as Dr David Campbell explains

Dysphagia is a frequent complication of stroke and can lead to serious complications. It is associated with increased morbidity and mortality rates; there is an increased risk of aspiration and associated respiratory infections, undernutrition and dehydration.

Incidence varies according to the definition of dysphagia and the method and timing of assessment. However, dysphagia is present in 64-90% of conscious stroke patients in the acute phase, and aspiration is confirmed in 22-42% of cases.1-3

Most cases of dysphagia following stroke resolve within the first few weeks; however, some persist, with long-term consequences for nutrition and psychosocial wellbeing.

SIGN’s recently published guideline, Management of patients with stroke: identification and management of dysphagia should help to ensure early detection and management of dysphagia in stroke patients and reduce morbidity associated with this disorder.

Guideline development

The guideline is relevant to all healthcare professionals involved in the care of stroke patients, from initial presentation through secondary care treatment to continuing care in the community. However, the strongest evidence base is for care and treatment in the acute setting.

The assessment and management of dysphagia requires a multidisciplinary approach, and this was reflected in the make-up of the development group, which was composed of health professionals from a wide range of disciplines.

Standard SIGN methodology was used to search for relevant literature (Figure 1, below). However,much of it was qualitative, and the paucity of high-level evidence highlights the need for continuing evaluation, audit and research in this area.

Figure 1: Key to evidence statements and grades of recommendations

Reproduced from Management of patients with stroke: identification and management of dysphagia by kind permission of SIGN

The guideline can be divided into two broad areas: screening and assessment, and management. A quick reference version has also been produced (Figures 2 and 3, below).

Figure 2: Front page of the quick reference guide

Figure 3: Reverse of the quick reference guide

Reproduced from Management of patients with stroke: identification and management of dysphagia by kind permission of SIGN

Screening

Assessing the risk of pneumonia

The guideline recommends that all stroke patients are screened for dysphagia before being given food or drink (Grade C).The risk of lower respiratory tract infection is increased in the presence of dysphagia.

The relationship between aspiration and pneumonia is complex. Pneumonia may occur in the presence or absence of aspiration.

The aspiration of solid material or thickened fluids leads to an increased risk of pneumonia. Other risk factors such as smoking, pre-existing respiratory disease, immobility or comorbidity will increase the risk of developing aspiration pneumonia.

Dental decay and other oral pathogens may be important risk factors for aspiration pneumonia in elderly patients.

Aspiration should be identified as soon as possible; the risk of aspiration is suggested by:

a wet, hoarse voice

a weak, voluntary cough

any indication of reduced laryngeal function

reduced level of consciousness.

Swallow screening

The water swallow test is a reasonably sensitive test and should be used as part of a screening assessment for aspiration risk in stroke patients (Grade B).

There are several similar swallowing screening procedures. A typical procedure should include:

initial observations of the patient’s consciousness level

observations of the degree of postural control

whether or not the patient is able to cooperate actively and to be supported in an upright position

observations of oral hygiene

observations of control of oral secretions

a water swallow test if appropriate.

Following acute stroke,many patients with dysphagia recover their ability to swallow within a week, and most improve by the end of the second week. Therefore, patients with dysphagia should be monitored daily in the first week to identify rapid recovery (Grade D).

Nutritional screening

Early and regular screening of stroke patients for undernutrition is important. Between 16 and 49% of stroke patients are undernourished on admission to hospital.

The guideline recommends that nutritional risk should be established within 48 hours of admission to hospital (Grade D), and that risk should be established with a valid and reliable screening procedure suitable for stroke patients (Grade D).

Nutritional screening should be repeated at regular intervals (Grade D). It should cover:

body mass index

ability to eat

appetite

physical condition

mental condition.

The result of the screening process should guide management, including referral to a dietician for assessment and management.

Dysphagia is associated with dehydration but there is no evidence on the clinical predictors of dehydration.

Methods of assessment

A standardised clinical bedside assessment should be used by a professional skilled in the management of dysphagia (Grade B), and the assessment developed and tested by Logemann or a similar tool is recommended (Grade B).

However, clinical testing has limitations, for example it does not easily detect silent aspiration or give good information on the effectiveness of any intervention.Therefore, an instrumental swallow evaluation should be available for all patients following acute stroke.

Modified barium swallow provides a comprehensive instrumental assessment of swallowing and is regarded as the ‘gold standard’, both diagnostically and therapeutically. It can determine whether the patient is aspirating and the reason for aspiration. It also enables clinicians to experiment with dietary textures and postures to improve swallowing.

FEES, which uses a flexible nasendoscope, is an inexpensive, portable and reliable alternative to MBS. However, it cannot be used to assess the oral stage of swallowing or bolus movement at the point of swallowing.

Both MBS and FEES are valid methods for assessing dysphagia, and the guideline recommends that clinicians should consider which is the most appropriate test for different patients in different settings (Grade C).

There is no current evidence to support the use of cervical auscultation or pulse oximetry in the assessment of dysphagia.

Speech and language therapists currently implement CBA; however, it is generally agreed that nurses play a vital role in identifying swallowing difficulties in stroke patients.

No single model of training for nurses emerges, but a training package should include risk factors for dysphagia, early signs of dysphagia, observation of eating and drinking habits, water swallow test, monitoring hydration, weight and nutritional risk.

Management

The principal management aim is maintaining and improving nutritional status. There are two methods of tube feeding in the patient with dysphagia: nasogastric and gastrostomy; each has advantages and disadvantages (Table 1, below).

Table 1: Comparison of tube feeding methods

NG feeding

PEG feeding

Insertion

Easy, quick

Invasive

Replacement

Often

Infrequent

Tube life

Up to 1 month

Several months

Patient acceptance

Poor

Good

Nutritional benefit

Uncertain

Some

Mortality reduction

None

Possible

Complications

+/-

++

Procedure-related mortality

Very low

0-2.5%

Nasogastric tube

Nasogastric (NG) tubes are easily passed, and the mortality rate associated with the procedure is low. However, care must be taken in passing the tube to avoid placing it into the lungs, which may have serious consequences. Nasogastric tubes are also less well tolerated than gastrostomy tubes and need to be replaced frequently. In addition, oesophagitis and upper GI ulceration can occur.

Gastrostomy tube

The most commonly used gastrostomy tubes in these patients are percutaneous endoscopic gastrostomy (PEG) tubes.They are tolerated more readily by patients and need to be replaced less frequently than NG tubes.

However, sedation and endoscopy are needed to place the tube, with the potential for complications. Minor complications include tube displacement, obstruction and skin infection, while major complications include gastric haemorrhage, abdominal wall infection, peritonitis and gastric fistula.

Following PEG placement, long-term mortality rates are high, which probably reflects the seriousness of the underlying stroke.

The guideline recommends that patients in the early recovery phase are reviewed weekly by the multidisciplinary team to determine whether long-term feeding (>4 weeks) is required (Grade D).

Medication

Patients with dysphagia have difficulty taking medicines, and administration through NG or PEG tubes has inherent problems. The guideline recommends seeking advice from pharmacists or medicine information centres on the most appropriate method of administering medication (Grade D).

Oral hygiene

Good oral hygiene should be maintained to reduce plaque and pathogenic organisms and prevent oral and dental disease, thus lowering the risk of aspiration pneumonia.

Review

Patients with persistent dysphagia should be reviewed regularly by a skilled professional to assess their swallowing function and dietary intake (Grade D), as some patients may recover swallowing function late after their stroke.

Diet modification and postures or manoeuvres are effective in some individuals. Texturemodified foods should be presented in an attractive and appetising manner (Grade D).

Quality of life and ethical issues

Failure to provide nutritional support in this group of patients is unethical. However, the risks and benefits of enteral feeding need to be weighed against outcome, particularly when considering PEG feeding as this has not been shown to improve quality of life.

Conclusion

The importance of recognising and assessing dysphagia after stroke lies in the reduction in resulting complications. These are principally risk of aspiration and pneumonia and undernutrition.

Dysphagia is not confined to the acute recovery phase; patients with long-term dysphagia present a management challenge to both carers and health professionals. The implementation of this guideline will ensure that the care of this vulnerable group of patients improves.

SIGN 78. Management of patients with stroke: identification and management of dysphagia can be downloaded from the SIGN website: www.sign.ac.uk